Los Angeles Prescription Denial Lawyer
Millions of Americans take prescription drugs every day. These prescriptions treat thousands of conditions. Some are even life-saving and can increase the person’s quality of life drastically. The downfall to prescription medications is that some are quite costly. In fact, about 12 percent of private health insurance spending in 2020 was on retail prescription drugs according to National Health Expenditure data from the Centers for Medicare and Medicaid Services. And drugs grow increasingly expensive. United States spending on prescription drugs increased 69% from 2004 to 2019. According to the American Society of Health-System Pharmacists, 2022 U.S. pharmaceutical expenditures were $633.5 billion, up 9.4% vs. 2021. Due to their high cost, in 2022 20.2 percent of adults 65 and older either delayed, skipped, took a smaller dose than prescribed, or consumed somebody else’s medication. Of course, prescription drugs are often expensive even with insurance coverage.
Furthermore, your insurance company may decide to deny certain, necessary prescriptions. However, paying out of pocket for some of these much-needed medications can be impossible. A Los Angeles prescription denial lawyer may be the key to getting your insurance company to approve a prescription drug your doctor has ordered. By fully examining the terms of your policy, an insurance denials lawyer can help make sure your insurance carrier is fully honoring their contract with you.
Reasons for Prescription Drug Denials
Health insurance companies are notorious for caring more about their financial health than the physical and mental health of the individuals and families they insure. One of the ways they accomplish this goal is by looking for different reasons to deny a claim. In a 2023 KFF survey of consumer experiences with health insurance over the past year, 23% of insured adults claimed their health insurance didn’t cover a necessary prescription drug or charged a high copay. When a prescription drug is denied by a health insurance company, it may be for one of several reasons.
Not Enough Evidence to Support Need
An insurance company may deny payment for a prescription, even when it was ordered by a licensed physician. This may be because they believe they do not have enough evidence to support the need for the medication. Getting detailed information in writing explaining the medical need for a prescription drug, either from the physician directly or via the office manager may help.
Additionally, a Los Angeles prescription denial lawyer can help the insured write a letter to their insurance company explaining why this prescription is a medical necessity. It should include the experience of the insured with the medication and how alternative medications or treatment do not produce as positive a result as this particular prescription.
Lacks FDA Approval for Condition
Another defense health insurance companies may use to deny a prescription drug claim is purporting that the medication is not FDA approved for the condition that the doctor has prescribed it for. Providing the insurance company with facts about how the medication has been used to treat this specific condition, such as reliable studies or even letters from other patients who have successfully taken this particular drug for the same condition can also sometimes help. A prescription denial attorney in Los Angeles can help determine what evidence could help reverse the denial.
Prescription Drug Insurance Laws in Los Angeles
Patients have several rights under California laws regarding prescription drug coverage. One of these laws covers step therapy, or the practice of insurance companies to mandate that patients try other similar medications before prescribing the one specifically requested by their doctor.
As per California Health and Safety Code Section 1367.243, a prescription drug plan cannot require an insured individual to try and fail more than two prescription medications prior to allowing them access to the medication that was originally prescribed. The only exception to this law is if there is clinical evidence that supports the patient trying more than two prescriptions before trying a requested medication.
Health and Safety Code of California
The existing Health and Safety Code of California was built on the Knox-Keene Health Care Service Plan Act of 1975, which provides for the licensing and regulation of healthcare plans by the Department of Managed Healthcare. The existing law prohibits any health insurance plan from excluding coverage of a specific drug because it was prescribed for something other than the official use approved by the FDA. Many medications have multiple uses, so this policy protects patients’ access to medications that may be prescribed off-label.
The newly passed amendment of the Health and Safety Code of California in SB 853, if passed into law, would further expand protections for insurance policyholders. Prior to this bill, health insurance companies had the ability to limit or deny coverage of a prescription that a policyholder had already been approved for and had already been using for some time. This action would not even be considered an adverse benefit determination, which means your health insurance would not have to notify you or provide an explanation for its coverage decision. This would also mean that even if you were to appeal this decision, you would not receive coverage for this prescription during the appeal process. Even if you were to win the appeal and your insurance must continue covering the prescription, appeal processes often take more than a month. In the meantime, you may have had to go without treatment or incur financial damage.
Benefits from California Senate Bill 853, the Medication Access Act
On September 20, 2022, the governor signed Senate Bill 853 into law. This bill amended Sections 1367.21 and 1367.22 and added Sections 1367.26 and 1367.28 to the Health and Safety Code of California.
The passing of SB-853 into law established a determination criterion for insurance companies to use. The amendment provides that a health insurance plan must not limit or deny coverage of a drug or a dose of a drug as prescribed, if the following apply: (a) the enrollee is currently undergoing a course of treatment and requests authorization for a continuation of coverage within a month of the date of expiration, (b) the medication was previously covered by the enrollee’s medical plan, and (c) the drug is prescribed for the enrollee’s medical condition and the drug is appropriately prescribed and considered safe. If these criteria are met, health insurance companies within California must not limit or deny coverage of these prescriptions. If the insurer denies a policyholder’s claim for coverage of medication, the insurer must base its determination on the preceding criteria.
How Does the Inflation Reduction Act of 2022 Impact Me?
The Inflation Reduction Act was signed into law on August 17, 2022. From a prescription standpoint, it helps seniors in many ways including those listed below:
- Heath and Human Services, on behalf of Medicare, will negotiate the price of 10 drugs starting in 2026. It will negotiate another 15 in 2027, an additional 15 in 2028, and 20 more in 2029 and all subsequent years. The negotiated drugs are limited to very expensive single source drugs that have been on the market for years and don’t have generic or biosimilar equivalents.
- Seniors on Medicare with Medicare Part D will have an annual medication out-of-pocket cap of $2,000 starting in 2025. This cap makes very expensive drugs more reachable for seniors. (In fact, a February 2024 KFF paper estimated that had this cap been in place in 2021, 1.5 million recipients with Medicare Part D would have saved money. And in future years, far more recipients will likely save money. That’s because 5 million enrollees spent $2,000+ out-of-pocket on prescription drugs in at least one year between 2012 and 2021.)
- Medicare Part D can only raise its premiums by 6% each year from 2024 to 2029.
- More lower-income individuals will be eligible for discounted rates on Medicare Part D starting in 2024. Prior to 2024, individuals who earned up to 135% of the federal poverty level were eligible for discounted drug prices and premiums. This act changes 135% to 150% of the poverty level making more people eligible.
- Individuals on Medicare will have a maximum out-of-pocket expense of $35/month for insulin starting in 2023.
- Pharmaceutical companies must pay a rebate to Medicare if they raise drug prices (prescribed through Medicare Part B) faster than the inflation rate starting in 2023.
- Vaccines will be free for seniors. Prior to this act, some vaccines such as the Shingles vaccine had a copay.
Does the act impact people who aren’t seniors on Medicare? The act extends the American Rescue Plan (ARP) subsidies for Affordable Care Act (ACA) health insurance plans through 2025. These subsidies drastically decrease premiums for people and enabled about 13 million more Americans to get health insurance. Also under the ARP, individuals don’t pay more than 8.5% of their income on ACA plan premiums. This extension is a big deal because in the 33 states that use the ACA exchange known as heathcare.gov, premiums would have increased over 50% without these subsidies.
From a prescription drug perspective, however, the Inflation Reduction Act of 2022 doesn’t impact people under the age of 65 who aren’t Medicare recipients. If you are in this group, you still face high prescription prices. In fact, one 2020 GAO study that compared the same 20 prescriptions in the United States to those in France, Canada and Australia found the US retail prices were two to four times higher than in the other countries. The study reported the actual differences are probably even greater because their numbers don’t reflect foreign country hidden discounts and rebates.
2023 Inflation Reduction Act Update: CMS Selects First 10 Drugs For Medicare Negotiation
On August 29, 2023, CMS announced the first ten medications for which it will negotiate the prices. The negotiated prices will be between 25% to 60% off of list prices depending on how long the specific drug has been on the market. The 10 include the blood thinners Eliquis and Xarelto, the diabetes drugs Jardiance, Januvia and Farxiga, the insulin meds known as NovoLog (and Fiasp), the heart failure medication Entresto, the rheumatoid arthritis drug Enbrel, the blood cancer medication Imbruvica, and the anti-inflammatory Stelara, often given to Crohn’s disease and ulcerative colitis patients. Given that many of these drugs are are close to their patents expiring, some analysts predict that the negotiations will have a negligible impact on their pharmaceutical manufacturers’ bottom lines.
Although the negotiations will be in 2023 and 2024, the new prices will be effective starting January 1, 2026. CMS revealed that the medications above accounted for $50.5 billion, or approximately 20% of total Medicare Part D gross covered prescription drug costs from June 1, 2022 to May 31, 2023. As many as 9 million Medicare recipients will save money on these medications. The Congressional Budget Office estimated that taxpayers will save about $160 billion.
What if Your Insurer Will No Longer Provide or Cover Your Medication?
If an insurance plan will no longer be providing coverage for a medication already being prescribed to a policyholder, the insurance company must notify the policyholder or their representative of an adverse benefit determination a minimum of 7 days before the effective date. Once a patient receives an adverse benefit determination, they will be able to file an appeal. The insurance company must continue providing coverage of the medical treatment unless and until the adverse benefit determination has been upheld through the appeals process.
If your insurance suddenly tells you that your medication is no longer covered, you have the right to appeal, and you are now entitled to receive coverage of your medication throughout the entire appeals process. This includes the coverage of any increase in a prescribed dose that may occur during the appeals process.
Let a Los Angeles Prescription Denial Attorney Help
Trying to get a prescription medication approved by your health insurance company can be frustrating. You may feel as if you are fighting an uphill battle and may even lose hope. However, a Los Angeles prescription denial lawyer can help.
An experienced attorney knows what it is like to have your insurance company deny a medication that you desperately need. They also know how California insurance laws apply in these circumstances.
Reach out to the Law Offices of Scott Glovsky. We’ve been fighting for the rights of health insurance policyholders for over 20 years. We understand how to navigate the insurance company system and can help.